Recruitment and Retention for Rural Health Facilities

Rural communities often face challenges in maintaining an adequate health workforce, making it difficult to
provide needed patient care or to meet staffing requirements for their facilities. Therefore, rural
healthcare facilities need to be proactive and strategic about recruiting and retaining personnel.

Recruitment focuses on attracting current health professionals and students to open positions
or to future positions. Retention focuses on keeping healthcare professionals employed in
their healthcare facilities and communities.

Successful recruitment and retention practices can minimize the number and duration of staff vacancies, which
can, in turn, save money, improve quality of care, and ensure that services are provided in the community.

This guide covers recruitment and retention issues including:

Strategies and incentives to help communities attract healthcare providers

Organizations and programs that support physician recruitment and retention

Where can rural communities get help in recruitment and retention activities?

As one of the largest and most comprehensive recruitment and retention resources,
3RNet (National Rural Recruitment and Retention Network) is a nonprofit network funded by the
Federal Office
of Rural Health Policy and member dues. Members are located in 49 states and the Commonwealth of the Northern
Mariana Islands, and include the Indian Health Service, the Cherokee Nation, and the Department of Veterans
Affairs. According to Executive Director Mike Shimmens, more than 1,000 medical professional placements are
achieved annually through 3RNet’s recruitment tools, with 90% of these in designated
shortage areas.

Some of the services 3RNet offers include:

A website where members maintain their state and regional pages

A database with over 56,000 profiles of providers, including medical students, interested in rural
healthcare services

The main focus of 3RNet’s efforts is to facilitate the placement of primary care physicians in organizations
known as “safety net providers.” These include:

Critical Access Hospitals

Rural Hospitals

Federally Qualified Health Centers

Public Health Agencies

Free Clinics

3RNet's Annual Report, 2015-2016 includes their placement
statistics and describes major accomplishments by staff and member organizations. 3RNet also publishes An Employer's Guide to Workforce Programs,
which provides an overview of Health Professional Shortage Areas (HPSAs), loan repayment programs, and the
Conrad 30 J-1 Visa Waiver program.

What is recruiting for retention?

Recruitment and retention are closely linked. Recruiting healthcare providers and acclimating them to a
community and facility are expensive, and often lengthy, endeavors. It is important to recruit providers who are
well-suited to the community in which they will work, and to be proactive in retaining those providers. This is
called recruiting for retention.

According to 3RNet, recruiting for retention involves having strategies in place, thinking long term, and
ongoing planning. It is often said that the best recruitment strategy is a good retention plan. Strategies
should focus on keeping rural healthcare providers employed in their healthcare facilities and communities
for a long time, thus avoiding turnover.

The most important steps in recruitment and retention of rural health professionals are planning and
preparation. Unfortunately, in rural communities these steps are sometimes neglected. Often turnover is high due
to lack of planning. Rural communities may find themselves without a provider on short notice. Communities that
spend time and money on both recruitment and retention are more likely to achieve success.
Retention-building efforts should be a constant and ongoing process combined with a community team approach.

Recruitment efforts should first and foremost strive to make an appropriate match for candidates, their
families, healthcare facilities, and the community. Factors that contribute to a good fit include:

Mission/purpose of the facility aligned to provider's purpose

Region of the country desired

Size of town/community desired

Amenities that match family interests, such as outdoor recreation, arts/culture

School availability and quality, if there are or will be school age children

The Community
Apgar Program, developed by collaborative partners in Idaho, is a tool for improving rural communities’
recruitment and retention of family practice physicians, nurses, and hospital administrators in Critical Access
Hospitals and Community Health
Centers. It identifies and weights factors important to each community regarding physician recruitment and
retention and assists with specific strategic planning and improvements.

Before recruitment efforts begin, such as placing an ad in a national journal or working with a recruiter,
attention should be given to planning and preparation when recruiting for retention. This includes:

Many rural communities are finding that “active” recruitment efforts pay off. Some traditional
efforts like
placing advertisements would be considered passive methods. Active
recruiting refers to efforts to proactively find and
build relationships with potential candidates. This allows
both the provider and the facility to assess whether there would be a good match between them.

Why might healthcare professionals be reluctant to practice in a rural setting?

Healthcare providers who are considering a job opportunity in a rural community may have a range of concerns
such as:

A heavy workload, with a large number of patients to see and patients who require more care

Difficulty taking time off

Few opportunities for continuing education

Professional isolation

Challenges in maintaining professional boundaries

A healthcare provider's family will also bring concerns to the table when considering a rural job offer.
Family concerns may include:

Limited job opportunities for spouses

Travel distances to attend school

Lack of afterschool programs and daycare

Rural healthcare facilities and communities can help job candidates consider some of the rewards that balance
out the challenges of a rural position. Rural practitioners can experience a greater sense of mission and
accomplishment because they serve in an area of need. They may also find they can develop stronger
relationships with patients whom they come to know in many other contexts in the community. There are also
personal rewards for both providers and their families: a lifestyle that has a slower pace, greater access to
the outdoors, and other factors that make rural life an appealing choice.

How can telehealth and other technology be used to make rural practice more attractive to candidates?

Using technology to lessen isolation and provide support to the rural health workforce can make working in a
rural setting more attractive. For example, South Dakota's Avera Health eCARE Emergency service uses two-way
video equipment in rural emergency rooms to communicate with and get support from emergency-trained physicians
and specialists at a central hub, 24/7. In Alaska, an eICU
system allows rural providers to collaborate with Anchorage intensive care unit staff, who assist in
monitoring and treating patients. For more examples, see RHIhub’s Telehealth Use in
Rural Healthcare guide.

Having electronic health records and other health information technologies in place can be an important factor
for younger providers who have learned to practice medicine with those tools in place. For more information on
electronic health records, see RHIhub’s Health Information
Technology in Rural Healthcare guide.

What are the impacts of staff vacancies on rural healthcare facilities and the communities they serve?

Quality of care is harder to maintain when the facility is understaffed. Staff may be working with fewer
people to cover the same number of patients and/or working longer hours. In addition, using temporary staff
may impact quality and coordination of care. In some cases, vacancies can even result in certain services not
being available in the community until the position is filled.

Impacts associated with vacancies may include:

Limited healthcare services to residents throughout the community as well as the surrounding area

What are options for recruiting international healthcare workers to rural communities?

Many communities recruit foreign medical graduates to fill physician vacancies. The Conrad
State 30 Program allows each state’s health department to request J-1 Visa
Waivers for up to 30 foreign physicians per year. In
addition to the J-1 Visa Waiver, non-immigrant H-1B
visas can sometimes be used to fill employment gaps.

What kinds of benefits and incentives can be included to make compensation packages desirable to potential
employees?

Added benefits and incentives can help organizations recruit and retain employees. These may include:

Insurance benefits

Health insurance

Dental insurance

Vision insurance

Life insurance

Professional benefits

Coverage of malpractice insurance

Payment for licensure fees

Payment for association dues

Payment for continuing education

Other benefits

Retirement packages

Paid time off

Sick leave

Leave for volunteer work

Sabbaticals for research, education, or mission work

Bonuses

Sign-on bonuses

Retention bonuses

Bonuses for meeting certain goals

Other incentives (especially for rural and underserved areas)

Low-interest home loans

Relocation expenses

Practice set-up costs

Assistance with finding spousal employment

Assistance with locating daycare

Underserved locations may qualify for loan repayment, which can be a significant incentive. According to Mike
Shimmens, Executive Director of 3RNet, offering loan repayment or forgiveness is critical in recruiting
primary care physicians to practice in underserved areas. Many of those reviewing online job boards and
websites are especially interested in this benefit.

Shimmens expressed his concern that,

“The number of primary care physicians available to serve in underserved
areas is trending down while the demand is increasing. Finding physicians to practice in these areas of need
is becoming incredibly more important and more difficult to do.”

How can I research what a competitive salary would be for a given health occupation in my region?

Professional, recruitment, consulting, and government organizations often survey healthcare providers or
employers for compensation information. Participating in these surveys is a good way to gain access to their
results. Research or educational organizations may also survey new graduates regarding starting salaries.

Recruitment and professional organizations may charge for wage data and some professional organizations limit
access to compensation information to members only.

The Rural Health Information Hub is supported by the Health Resources
and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS)
under Grant Number U56RH05539 (Rural Assistance Center for Federal Office of Rural Health
Policy Cooperative Agreement). Any information, content, or conclusions on this website are
those of the authors and should not be construed as the official position or policy of, nor
should any endorsements be inferred by HRSA, HHS or the U.S. Government.